Abstract
The recent dramatic growth in private healthcare in Australia’s mixed public/private healthcare system has brought a new imperative to the investigation of decision-making and choice. This chapter draws on a study of key players in the healthcare system, the ‘gatekeepers’ who control access to resources and services and shape patients’ experiences of healthcare. The analysis draws on in-depth interviews with 43 gatekeepers (general practitioners [GPs], specialists, nurses, hospital administrators and policy-makers) in the private, public and not-for-profit sectors. Employing Bourdieu’s concepts of habitus, field, market and state, the study explores the impact of neoliberalism on the gatekeepers, finding connections between their perspectives on the state, the market and social justice, and their locations within the field. The analysis provides insight into differing perceptions of ‘public’, ‘private’, the role of the state and social justice across this key group of actors, and suggests neoliberalism has had both direct and indirect effects on their understandings and practices.
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Notes
- 1.
Australia has a federal system of government, meaning that it has a central, federal (or Commonwealth) government and six state governments. Powers and responsibilities are divided between them, and these are set out in the constitution. The states have the autonomy to make laws over matters not controlled by the Commonwealth. In Australia, unlike the USA, federal law overrides state law in the case of any contradictions. There are also eight territories, with the largest being the Northern Territory and the Australian Capital Territory. These do not have the full autonomy of the states, and their powers are not defined by the constitution but by Commonwealth law. The division of powers and responsibilities between the Commonwealth and state governments relevant to healthcare are complex (for an overview, see https://beta.health.gov.au/about-us/the-australian-health-system).
- 2.
Bulk billing is a payment option under the Medicare system of universal health insurance in Australia for medical services occurring outside hospitals, and when it is agreed to by doctors/practices, the patient does not have to pay fees at the point of service. Instead, the doctor/practice accepts the Medicare benefit (between 85 and 100 per cent of the Schedule fee) as full payment for the services rendered, and the doctor/practice recovers the Schedule fee directly from Medicare. Alternatively, doctors accept the Schedule fee from Medicare plus an additional charge from their patients. Not all doctors/practices offer bulk billed services, but incentives are offered (in certain eligible areas) by the government to bulk bill pensioners, healthcare card holders and those aged 16 and under, in an effort to increase access to services across the population and limit the possibility of bad debts.
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Acknowledgements
I would like to acknowledge the participants of the gatekeeper study for their time and thoughtful contribution to this project; the Australian Research Council and the University of Sydney for funding the field work; and colleagues, including Karen Willis and Sophie Lewis, without whom the project would not have been either successful or enjoyable; and Jon Gabe of Royal Holloway, University of London, for his thoughtful comments on the manuscript.
Note: Approval for the gatekeeper study was sought from a plethora of ethics committees at a variety of institutions. Primarily this was the Human Ethics Committee (HEC) at the University of Sydney, as well as the various authorities with responsibility for ethical conduct in the public hospital system in each state.
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Collyer, F. (2020). Chapter Six: Gatekeepers in a Mixed Private/Public System. In: Collyer, F., Willis, K. (eds) Navigating Private and Public Healthcare. Palgrave Macmillan, Singapore. https://doi.org/10.1007/978-981-32-9208-6_6
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